Difference between flare up and reducing too quickly?

[GinnyMa]

With GCA what is the difference in symptoms between a flare up and the result of reducing dose too quickly. Does it matter ? Is the solution the same...just go back to previous dose. The only advice I was given was that if the headache returned then go back to the previous dose.

[PMRpro Ambassador]

The most common cause of a flare is reducing too quickly - that has been stated in the medical literature for a long time. You have taken away the thing that is controlling the inflammation - and that is all steroids do, manage the symptoms until the disease goes into remission - so the symptoms reappear.

If you reduce in reasonably small steps you won't have problems with steroid withdrawal symptoms - which can be very similar to the symptoms of the original illness you were taking the pred for. That's the basis of the "Dead slow and nearly stop approach" where the reduction is not only small but spread over a few weeks.

In the early days of reducing the pred dose from (say) 40mg or more, many doctors suggest 10mg at a time, sometimes 5mg at a time, and from one day to the next. When they have been on such high doses for a while some people find it becomes difficult to reduce in steps of that size. Often they are fine reducing more often but 2.5mg at a time. A basic rule is that any reduction should not be more than 10% of your current dose - and obviously that means that more than 5mg is always going to be too much.

So it depends - the return of the headache may simply be that the reduction you tried was just too big for your body to accept rather than it allowed the inflammation to build up again. Steroid withdrawal usually improves over a period of a few days while a flare tends to get worse from day to day - which is a good way of deciding in PMR. It's a bit more critical in GCA though so all the more reason to reduce in small steps.

[cassey1879 in reply to PMRpro]

Very good information, thank you. How long should you stay on the reduced dose. I originally was on 60 for GCA went down to quickly so she took me back to 40 for two or three months. I went down from 32 to 27.5 (my 6th day) 4 weeks ago today. Wanted to go down to 27 tomorrow as long as I am not seeing the enlarged temporal arteries, of eye and jaw pain. So how long do you think you should stay on a small reduced dose? A week? Three weeks? etc.? I am only going down a mg. or 1/2 as don't want to go on the methotrexate due to small kidney. Thanks. This website is AMAZING in knowledge and WONDERFUL people. Wish could find more infor. in the states.

[PMRpro Ambassador in reply to cassey1879]

Have you seen this reduction plan?

healthunlocked.com/search/d...

Doing this you might well manage 2.5mg at this stage and it is so slow, spread over about a month, that you would realise if it was being too far.

I have to say - I feel to say you should reduce if you "are not seeing the enlarged temporal arteries, of eye and jaw pain" is a bit cavalier. That is a pretty advanced stage of GCA - a lower level of inflammation can be found with imaging that hasn't got to a stage that is visible superficially. Most reductions for GCA suggested by rheumies reduce in 5mg steps to 20mg and keep you at each dose for a month. Research a year or 2 ago showed there is evidence of GCA present even after 6 months at above 20mg even though there are no symptoms and the blood tests are normal.

It is when this is the case and a rheumy suggests a drop in dose that is too much that the flares will occur - they are very common in the first 18 months after diagnosis of GCA and I think that is probably more a reflection of haste to get off pred rather than the illness flaring up more than it was previously. The primary cause of flares has been recognised as reducing too far or too fast - in some cases it may be because the disease becomes more active but that is less often the case I think.